Integrating human factors

into incident investigation

Dr Jane Carthey, Human Factors Specialist
Overview of the workshop
1. Discuss what a human factors-based approach
to incident investigation looks like.
2. Explore the current challenges faced by
healthcare teams when carrying out incident
investigations
3. Forum for sharing ideas for integrating human
factors into incident investigation
Getting started
Look at the photograph
Discuss what you see with the person next
to you
Quick task
Reflect on your comments and decide which ones
are Facts and which are Assumptions


Current approaches &
Challenges
The London Protocol
www.cpssq.org
Not about whodunnit
Challenges
Cognitive biases: hindsight and outcome bias
Witness memory degradation
Paradigms
Place (the
clinical area,
equipment
involved).

Paper (i.e. documentation)
(medical records, shift
rotas, incident report,
complaint letter etc..)
People (i.e. those who were involved and
also who witnessed what happened)
- Use interviews, witness statements
Most obscure!
Tapping into
the way we do things
around here

Timelines mapping can go too far!!



The sorry lot of the healthcare
incident investigator
Two days training in incident investigation methodology
Demand means that you go straight from theory into practice.
Learning on the job.
Training does not prepare you for the emotional aspects.
Investigation carried out alongside the day job
Infra-structure within a Trust to peer review, mentor and support.
Investigators have to be clinical ly trained -
Human factors expertise not included as standard



Focus on the active errors, not the system
failures
Intrathecal vincristine administration
Active error: two junior doctors checking error
Often identified as the root cause
But making a recommendation to improve checking or to add
in additional checks leaves other important latent failures in
the system
Therefore there is a real risk that the incident will happen
again
STRONG
ACTIONS
Physical plant or equipment re-design
New device with usability testing before purchasing
Engineering controls (interlock / forcing function)
Simplify the process and remove unnecessary steps
Standardise equipment or processes or care plans
Tangible involvement and action by leadership in support of
Patient Safety
MODERATELY
STRONG
Increase in staffing / decrease in workload
Software enhancements / modifications
Eliminate / reduce distractions
Checklist / cognitive aid
Eliminate look and sound-a-likes
Enhanced communication
WEAK
ACTIONS
Double checks
Warnings and labels
New procedure / policy
Training
Disciplinary action
Solutions and recommendations
Lee and Hirschler
Intuitive design
Make it possible to only
carry out a task one way
the safe way!
Think intuitive!
Design to do safely
Content atrainability 2010 & JC Consulting
PERFORMANCE
V
E
R
Y

U
N
S
A
F
E

S
P
A
C
E

Belief
Systems.
Life Pressures
The posted
speed limit is
70 mph- the
legal space
INDIVIDUAL BENEFITS


Driving 75
mph- the
Illegal-
normal
space
Driving
95+ mph
the illegal-
illegal
space (for
almost all
of us!)
Perceived
vulnerability
ACCIDENT
Systemic Migration to Boundaries (Amalberti, 2008)
Factors that increase non-compliance
Perceived low likelihood of detection
Lack of awareness/understanding of policies and procedures
Misperception or lack of recognition of risk
Self-perceived authority to violate
Time pressure/pressure to get the job done
Copying behaviour (i.e. learn to do the procedure from a colleague who is non-
compliant)
Lack of leadership
Lack of end-user engagement when policies and procedures are written.
Policy and procedure overload (for example, confusion over which procedure applies
when)
Ambiguous or conflicting messages in the policy/procedure
Lack of training and reinforcement of key policy messages over time.
No sanctions imposed for non-compliance
Lack of monitoring systems to check procedural compliance
Policies and procedures are inaccessible
Out of date procedures/policies
Mismatch between the policy/procedure and how the job is actually done.
Carthey 2011
Considering human factors in design:
Infection control tannoys
Great idea butno timer
Keep patients awake at night
So ward staff switch them off
because the design of the
tannoy enables this
workaround.
Capacity for 2 messages
Infection control and.
Please help us to reduce our
carbon footprint, recycle your
waste

WSS tendon repair incident
i. Operation requires use of splint which obscured the finger
involved
ii. Prep fluid removed initial marking
iii. WHO Surgical Safety Checklist carried out before prepping and
draping

ONLY NUMBER 3 IDENTIFIED AS A ROOT CAUSE
FOCUS ON THE PROXIMAL CAUSE
INVESTIGATOR FOCUS ON POOR DOCUMENTATION OF WHAT
HAPPENED IN THE CLINICAL NOTES AS A CONTRIBUTORY FACTOR
Yorkshire Contributory Factors Framework

Lawton et al., 2011. BMJ Qual Saf doi:10.1136/bmjqs-2011-000443
Never! (CHFG, 2012)
Equipment
Poor planning meant imaging equipment needed in more than one place at the
same time
Skin marking pens not always available; procurement and stock management
failures
Theatre table design that means turning it round loses visual cues
Information, data and records
Delays in patient records being filed
Multiple, pre-printed name labels meant any mistakes were perpetuated
Not all information available at MDT meetings
Abbreviations leading to errors RT and groin misinterpreted
Jobs/tasks/protocols
Surgeons operating without having had time to see patients or read their notes
Management meetings or meetings on other sites conflicting with theatre times
Environment
Working in theatres with different layouts display boards not visible, table and
equipment laid out the opposite way round

Work carried out by Susan Burnett, Joan Russell, Beverly Norris and Rhona Flin
Never! (CHFG, 2012)
Work design
The WHO Checklist seen as an added, unnecessary task rather than an integral part of process
Staff breaks and interruptions were not planned for
Culture and organisation
Acceptance of time pressures causing shortcuts and failures to follow procedure
Hierarchies preventing staff speaking up or asking for help
Poor safety culture meant the checklist was seen as a burden rather than a tool for staff to protect
themselves against errors
Communication
Between frontline staff and management:
Poor consultation on new ways of working
Staff patient communication:
Issues with obtaining consent/patient involvement
Poor access to translator services
Communication between teams and different staff groups:
Failures to speak up when checklist not followed
Lack of a double checking protocol when side for
procedure is not obvious, e.g. when viewing on screen
Organisation
Unrealistic expectations of staff to cope with time pressures and workload

Work carried out by Susan Burnett, Joan Russell, Beverly Norris and Rhona Flin
What does a good HF approach look like?
How might we ensure that human
factors is better integrated into
incident investigations in healthcare?
Just a Routine Operation
Reasons Swiss cheese model
Patient Safety
Incident
LATENT
CONDITIONS
: poor
design,
procedures,
management
decisions
etc..
ACTIVE ERRORS
Levels of defence